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Should Physicians “Just Say No” to MACRA? – MACRA Monday

Posted on January 9, 2017 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This post is part of the MACRA Monday series of blog posts where we dive into the details of the MACRA Quality Payment Program.

We’d planned to start diving into MIPS this week, but I couldn’t resist commenting on a post I saw on Medical Economics where a physician makes the case that physicians should just say “No” to MACRA. The opening paragraph describes the challenges of MACRA (and its meaningful use predecessor) pretty well:

I can’t recall the exact moment I crossed over from believer in today’s version of the healthcare quality movement to skeptic. Perhaps it was when the office trash would fill with clinical summaries the staff dutifully handed out to patients to satisfy a “meaningless use” measure. Or maybe it was trying to convince a 75-year-old Mrs. Davis that we would really appreciate it if she logged on to our electronic health record (EHR) using the patient portal. To do what, she asked? I stared back at her blankly.

It’s easy to make the case that some of the meaningful use requirements are meaningless. The same could be said for MACRA. That’s particularly true if you look at specialty specific instances where certain requirements made no sense to specific specialties. In other cases, the concept is good, but the execution is poor. For example, the concept of giving patients access to their health information is good, but it was poorly executed. Providing a clinical summary after a visit doesn’t really get us there and yet that’s what doctors were required to do.

Long story short, I understand why many see meaningful use and now MACRA as a distraction and they should just say no to both. In fact, that’s the advice that the author above offers:

My advice to physicians operating in this climate is simple: Don’t participate. MACRA clearly is the law of the land, and while one may hope the implementation from a Trump-Price administration will have a much lighter touch than the Obama-Burwell administration, sustained resistance in the form of non-participation is a small but important message to send to policymakers.

It is true that opting out of MACRA would send a small message to policymakers. If doctors would opt completely out of Medicare to avoid the MACRA penalties, that would send an even stronger message. I hear some doctors talking about this as an option as well. Both actions would send a message if doctors did this in mass. The problem is this isn’t happening and I don’t think it will happen.

While it is easy for a well paid cardiologist to say in a blog post that doctors should just say no to MACRA, my experience is that the MACRA math is much more difficult for general medicine and other specialties that don’t get paid as much and have large Medicare populations. The 4% MACRA penalty is a significant penalty to many doctors and “just saying no” is a very challenging decision for them financially. In fact, I’ve talked to many that just don’t see it as an option.

The same is true for people opting out of Medicare or reducing their Medicare population so the penalties aren’t as damaging. Not only is Medicare a significant source of revenue for many practices, but opting out of Medicare would hurt many patients who would have challenge finding care without them. Indeed, choosing to accept the Medicare penalties is not as easy a decision as some like to make it seem.

If you believe MACRA will fail, then opting out wouldn’t be as hard to handle for a year at a 4 percent penalty. However, I don’t see a scenario where MACRA fails so badly that it goes away. In fact, given the budget neutral nature of the legislation and the MIPS Pick Your Pace changes, it’s easy to see how MACRA is going to be proclaimed as a successful program. It would take some really serious lobbying for MACRA to disappear and I don’t see the will in Washington to make this a reality.

Assuming MACRA sticks around, your initial 4% penalty will grow to 9%. That’s a big hit to the bottom line for many practices. Given the Pick Your Pace options and the fact that most are already doing many pieces of the MIPS program (PQRS and Meaningful Use), why would a practice just take the penalty on the chin when the penalty is easily avoided? Out of honor and principle?

In fact, if you want to minimize MACRA’s impact on your practice it might send a clearer message to Washington if everyone participated at the lowest Pick Your Pace (Test Pace) option as opposed to a few people opting out of MACRA completely. If a few people opt out of MACRA and take the penalties, that will just fuel the incentives of those that participate in MACRA. If the majority of doctors do the minimum required to avoid the penalties, then they’ll avoid the penalties and it will send a message to CMS that they need to continue at a slower pace. Plus, those that participate fully will only get a small increase because there aren’t enough penalties to pay them what MACRA could pay them.

I previously suggested that the best strategy for most practices would be to go and participate as much as possible in MIPS so that a practice doesn’t get behind. I still think getting behind is an important concept to consider when you evaluate your MACRA participation. However, given the budget neutral nature of MACRA and the way it minimizes the incentives for full participants, I’m ok with a practice that chooses to take MACRA slowly. I just think most practices with a reasonably sized Medicare population are a bit crazy to not at least avoid the MACRA penalties.

Feel free to send a small message by just saying no to MACRA, but don’t expect that strategy to achieve the goals you desire. In fact, all it will likely do is damage yourself and put you in a harder position to participate in MACRA in future years. Of course, if you’re a highly paid specialist and/or you have a small Medicare population, then you’re choice doesn’t matter much to you or them anyway.

I agree that we should make an effort to get government regulation out of the EHR world as much as possible. It’s stifled innovation, burnt out doctors, and commoditized EHR software. I dream for the day when doctors love technology because it helps them be better doctors as opposed to better medical billers and government hoop jumpers. However, “just saying no” to MACRA won’t get us there.

Be sure to check out all of our MACRA Monday blog posts where we dive into the details of the MACRA Quality Payment Program.

MACRA is Required by Law to Be Budget Neutral – What’s The Impact? – MACRA Monday

Posted on January 2, 2017 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This post is part of the MACRA Monday series of blog posts where we dive into the details of the MACRA Quality Payment Program.

In my last post on MIPS benefits and the “Pick Your Pace” options, I published an old slide which highlighted the potential positive and negative payment adjustments under MIPS. Thanks to Lynn Scheps from SRSsoft (she also wrote our previous Meaningful Use Monday series of blog posts), it was pointed out to me that there’s one big caveat to how much positive payment adjustment you’d receive under MIPS. I don’t know how I missed it on page 1282-1286 of the final rule. It was such an important point, that I wanted to dive into all the details in a MACRA Monday post of its own.

This all gets pretty technical, pretty quickly, but we’ll try to make this as simple to understand as possible. The core issue at hand is that the MACRA program has to be budget neutral. This means that the MACRA penalties have to offset any MACRA benefits that are paid to participants. Since Pick Your Pace has made it so very few practices will receive the 4% MACRA penalty, that means that there won’t be as big of a pool of incentives available to those who do participate in MACRA.

The math gets pretty complicated, but this chart illustrates how the adjustments you receive could be effected by the need to make the program budget neutral:

This chart is illustrative, but I also believe that it’s a decent representation of what’s likely to happen given the lack of MIPS penalties that will be assessed. If the chart is accurate, most MIPS participants will receive less than a 1% incentive and exceptional performers will be less then 2.4%. That’s quite a big difference between the 4% that was originally discussed.

Now remember that CMS was stuck in a tough position. They had a legal requirement to make it budget neutral. They could have continued with the 4% positive payment adjustment, but that would mean that a whole bunch of practices would get a 4% negative payment adjustment. Instead, they chose to do Pick Your Pace to give people a chance to avoid the penalties. Now those people are happy, but exceptional performers pay the price because there’s no budget to reward the exceptional performers.

At least this is how I read the legalese. If anyone has any other nuances I missed, please let us know in the comments. Next week we’ll start diving into more of the MIPS Categories and changes to the MIPS Composite Score.

Be sure to check out all of our MACRA Monday blog posts where we dive into the details of the MACRA Quality Payment Program.

MIPS Benefits and Pick Your Pace – MACRA Monday

Posted on December 19, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This post is part of the MACRA Monday series of blog posts where we dive into the details of the MACRA Quality Payment Program.

As promised, we’re back with another MACRA Monday looking at the MIPS Pick Your Pace options. However, before we dive into Pick Your Pace, we want to take a second to look back at the details of the MIPS incentives and penalties that are available as well. This really didn’t change in the final rule, so it’s review for those who have been following MACRA Monday since the beginning.

If you remember from last week’s MACRA Monday post, what you do in 2017 will determine your MIPS payment adjustment in 2019. Assuming you perform at the top level, you can get a full 4% positive payment adjustment to your Medicare Part B reimbursement (Note: It was pointed out to me that the MACRA program has to be budget neutral, so while they can give up to a 4% positive payment adjustment, it won’t be a 4% positive payment adjustment if enough practices aren’t penalized. With Pick Your Pace, hardly anyone will be penalized. On page 1282-1286 of the final rule it highlights this and points out that with the budget neutrality scaling, the upward adjustment is estimated to be under 1% for the base and 2.4% for exceptional performers. Thanks Lynn Scheps for the clarification!). Of course, if you don’t participate in MIPS, you’ll get a 4% penalty. That scales up to 9% in 2022. There are some exceptional performance bonuses as well, but we’ll cover that in a future MACRA Monday.

In the MACRA final rule, CMS added a number of other ways for doctors to participate in MIPS. They call the various options Pick Your Pace since the provider can choose how much they want to participate in MIPS in 2017. Here are the 3 MIPS Pick Your Pace options (and the Advanced APM for completeness’ sake):

As is laid out above, you can fully participate in MIPS for the entire year and get the largest positive payment adjustment. You can report on 90 days and receive at least a small positive payment adjustment and up to the full positive payment adjustment. Or you can just submit something to MIPS and that will have you avoid the negative MIPS payment adjustment.

The “Test Pace” option as it’s listed above needs some further clarification. Basically, if you don’t want to fully participate in MIPS, but want to avoid the negative payment adjustment you can just do 1 quality measure, 1 improvement activity, or the required advancing care information measures.

Clear enough? Basically, in 2017 they’ve made it so pretty much everyone should be able to at least do the Test Pace portion of MIPS and avoid the 4% negative payment adjustment. I don’t know of any practices where this wouldn’t be a reasonable goal. However, is that the best approach for a practice? I think not.

If I were advising a practice today, I’d suggest they shoot for full MIPS participation in 2017. Assuming they do well, they’ll get the full 4% payment increase and even could qualify for bonus payments. If they fall a little short, then they should still easily qualify for the MIPS partial year option which will provide them a small positive payment adjustment. If they experience a disaster with their MIPS participation, then they will still avoid any penalties.

Why is this my suggested route? MACRA and MIPS aren’t going anywhere. Sure, they might go through various iterations and subtle changes, but the move to this kind of reporting is here to stay and even a Trump presidency isn’t likely going to change this. Plus, you don’t want to be behind the 8 ball in 2018 when the full MIPS requirements will be upon us (Remember my post about thinking about MACRA like med school). You don’t want to get so far behind that you can’t catch up. If that’s still not enough, many people believe that the commercial payers are going to follow suit. Those that have participated in MACRA will be better prepared when they do.

Those are the details on MIPS pick your pace. We may take next week off from MACRA Monday for the holidays, but the next week we’ll be diving into more of the details of MIPS and other changes to the MIPS Performance Categories.

Be sure to check out all of our MACRA Monday blog posts where we dive into the details of the MACRA Quality Payment Program.

MIPS Timeline and Eligibility – MACRA Monday

Posted on December 12, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This post is part of the MACRA Monday series of blog posts where we dive into the details of the MACRA Quality Payment Program.

In the MACRA final rule, the timeline for MIPS was largely the same. However, I think there was some confusion on the MIPS timeline. So, while this isn’t a change from the MACRA proposed rule, I thought it would be worth highlighting the MIPS timeline for those that will be participating in the MIPS part of MACRA.

This graphic is the most succinct illustration of the MIPS timeline I’ve seen:
mips-timeline

As a summary, data for MIPS will be collected during 2017. How much data needs to be collected depends on which “Pick Your Pace” option you choose (more details on this in a future post). You must submit your MIPS data by March 31st following the performance year. Then, the positive or negative payment adjustment will happen the year after. For example, the 2017 MIPS performance year will determine your Medicare adjustment that goes into effect in 2019.

There was a slight change in who is eligible for MIPS in the MACRA final rule that is going to have a big impact. First, let’s take a look at who is eligible for the MIPS program:
mips-elibility

As you’ll see, there isn’t really a change in which types of providers are eligible for MIPS. However, you do have to have $30,000 in Medicare Part B billing and 100 Medicare patients a year in order to be able to participate in MIPS. Currently this is done on a per provider basis. They’re still considering virtual groups in future years.

There are 3 exceptions for providers that aren’t eligible to participate in MIPS. The newly enrolled doctors and Advanced APMs participants is the same as it was in the final rule. However, the low-volume threshold exception now excludes you from participating in MIPS if you have less than $30,000 in Medicare Part B or see 100 or fewer Medicare Part B patients. That’s a change from the proposed rule.

Here’s the full outline of the 3 MIPS exemptions:
mips-exclusions

That’s a quick look at the MIPS Timeline and Eligibility from the MACRA final rule. Next week we’ll dive into the details for Pick Your Pace. That should help you make a determination for how your practice should approach MIPS in 2017.

Be sure to check out all of our MACRA Monday blog posts where we dive into the details of the MACRA Quality Payment Program.